2013 Lone Star Blood Cancer Conference Registration
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First Name
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Last Name
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Street Address
Address Line 2
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City
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State
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
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Washington DC
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Zip Code
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Phone Number
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Email Address
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Morning Breakout Session: [Type letter of breakout session in box below - choose only one.]
A. Cancer Survivorship: What Comes With the New Normal?
B. Multiple Myeloma – Disease and Side Effect Management
C. Symptom Management for Survivors: The Key to Achieving Optimal Quality of Life
D. Health Insurance & Health Care Options (offered again in closing afternoon breakout)
E. Living with Graft Versus Host Disease (GVHD)
F. Long Term Effects for Pediatric and Young Adult Survivors of Leukemia and Lymphoma
G. Not attending morning breakout session
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Lunch Panel: [Type letter of panel in box below - choose only one.]
A. Age 0-18
B. Age 19-39
C. Age 40-60
D. Age 61+
E. Not attending lunch panel
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2:00 p.m. Afternoon Breakout Session: [Type letter of breakout session in box below - choose only one.]
A. Lymphomas – Disease & Side Effect Management
B. Caregivers Have Cancer, Too!
C. When Treatment Fails – Understanding Palliative and Hospice Care
D. Employment & Taking Time Off
E. Fighting Cancer with Nutrition
F. Recent Progress in the Treatment of Leukemias in Children and Adolescents
G. Not attending this afternoon breakout session
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3:15 p.m. Afternoon Breakout Session: [Type letter of breakout session in box below - choose only one.]
A. Fertility Preservation Options for Cancer Patients
B. Families Have Cancer, Too – Helping Your Children Cope with Cancer
C. What Do I Do If It Comes Back? New Treatment Developments for Hematologic Malignancies
D. Health Insurance & Health Care Options (repeat of morning breakout session)
E. Myelodysplastic Syndromes – Disease & Side Effect Management
F. Not attending this afternoon breakout session
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Do you want to receive continuing education credits (nursing or social work)?
No (patients/survivors, caregivers, parents)
Nursing CEUs
Social Work CEUs
Other professionals can request a certificate of completion. Please indicate if you want a certificate of completion at the conclusion of the conference to submit to your professional board.
Yes
No
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License number (nurses and social workers - required). If not a nurse/social worker, please enter NONE:
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Who am I:
Patient/Survivor
Caregiver
Nurse
Social Worker
Other
If other, please explain here:
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Diagnosis:
None - caregiver, parent or professional
Non-Hodgkin Lymphoma
Hodgkin Lymphoma
AML - Acute Myelogneous Leukemia
ALL - Acute Lymphoblastic Leukemia
CML - Chronic Myelogneous Leukemia
CLL - Chronic Lymphocytic Leukemia
Multiple Myeloma
Waldenstrom’s Macroglobulinemia
Myelofibrosis
MDS - Myelodysplastic Syndromes
Other
If other, please explain here:
Year of diagnosis:
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How did you hear about the conference?
Brochure mailing
Website
Emailed invitation
Doctor's office
Other
If other, please explain here:
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Have you ever attended the Lone Star Blood Cancer Conference?
Yes
No
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Do you need assistance with accessibility?
No
Yes
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Indicates Response Required